Airbag Performance in General Aviation Restraint Systems

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1 Airbag Performance in General Aviation Restraint Systems Safety Study National Transportation Safety Board NTSB/SS-11/01 PB

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3 /SS-11/01 PB Notation 8274 Adopted January 11, 2011 Safety Study Airbag Performance in General Aviation Restraint Systems National Transportation Safety Board 490 L Enfant Plaza, S.W. Washington, D.C

4 National Transportation Safety Board Airbag Performance in General Aviation Restraint Systems. Safety Study NTSB/SS-11/01. Washington, DC. Abstract: In 2003, airbags were first certificated for pilot and copilot seats on general aviation (GA) aircraft, and as of August 2010, they have been installed in nearly 18,000 seats in over 7,000 GA aircraft. In 2006, the National Transportation Safety Board (NTSB) initiated an exploratory case series study to consider airbag performance in GA accidents. The goals of the study were (1) to examine the effectiveness of airbags in mitigating occupant injury in GA accidents, (2) to identify any unintended consequences of airbag deployments, and (3) to develop procedures to assist investigators in documenting airbag systems in future investigations. During the 3-year data collection period, researchers tracked 145 notifications of events involving airbag-equipped airplanes which yielded 10 airbag-equipped GA airplane accidents that met the study criteria and were subjected to a full review and analysis by a multidisciplinary team. There were no unexpected deployments or unintended consequences identified during the study period. When adjusted correctly, the deployment of the airbag systems did not result in any negative outcomes, and in certain cases, deployment mitigated the severity of occupant injuries. The NTSB concluded that aviation airbags can mitigate occupant injuries in severe but survivable crashes in which the principal direction of force is longitudinal. During the course of the study, the study team also became aware of several potential issues that may compromise occupant safety associated with use, adjustment, or design of restraint systems. The report discusses steps that could be taken to address these safety issues and suggests future research directions in the area of GA occupant protection. Finally, as a result of the study, guidance for NTSB investigators was developed and disseminated, including a formal process for gathering data about airbag installations and deployments in accident aircraft. The National Transportation Safety Board (NTSB) is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The NTSB makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Recent publications are available in their entirety on the Internet at < Other information about available publications also may be obtained from the website or by contacting the NTSB at this address: National Transportation Safety Board Records Management Division, CIO L Enfant Plaza, SW Washington, DC (800) or (202) NTSB publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To purchase this publication, order report number PB from this address: National Technical Information Service 5285 Port Royal Road Springfield, Virginia (800) or (703) The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of NTSB reports related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report.

5 Contents Contents... i Figures... iii Acronyms and Abbreviations... vii Executive Summary... ix Chapter 1: Introduction...1 History of GA Occupant Protection Systems...3 NTSB Recommendation History...5 Research on the Effectiveness of Aviation Airbags and Other Occupant Protection Systems...6 Research Methods and NTSB Research...8 Automotive Airbag Systems...9 Description of Current GA Airbag Systems...10 Airbag Deployment...11 Standards and Certification of GA Restraint and Airbag Systems...14 Purpose of the Current Study...16 Chapter 2: Methodology...18 Case Series Methodology...18 Study Procedures...18 Accident Scene...20 Airplane Damage...20 Restraint Systems and Airbags...20 Glass Cockpit Display Unit Data...22 Occupant Interviews and Injury Documentation...24 NTSB Team Case Reviews...24 Study Limitations...25 Chapter 3: Results...27 Summary of Airbag-Equipped Events During the Study Period...27 Cessna Skyhawk and Skylane...30 Cirrus SR20 and SR Aviat Husky A-1B...33 Chapter 4: Accident Analyses...35 Boyceville, Wisconsin, August 5, 2006, Cirrus SR Owyhee, Oregon, August 27, 2006, Aviat Husky A-1B...39 Indianapolis, Indiana, August 28, 2006, Cirrus SR Athens, Texas, February 27, 2007, Cessna T182T...47 Fullerton, California, September 30, 2008, Cessna 172S...54 Groton, Connecticut, November 19, 2008, Cessna 172S...57 i

6 Green Cove Springs, Florida, November 19, 2008, Cirrus SR Steamboat Springs, Colorado, February 14, 2009, Cirrus SR Stigler, Oklahoma, April 9, 2009, Cessna 182T...67 Boyd, Texas, July 14, 2009, Cessna 172S...71 Summary of Results...74 Chapter 5: Discussion...77 Effectiveness of GA Airbag Systems in Mitigating Occupant Injury...78 Issues Associated With Restraint Systems...79 Incorrect Usage or Adjustment of Restraint Systems...79 Restraint Design Issues Affecting Nonnormative Populations...80 Shoulder Harness Use...82 Future Aviation Occupant Protection Research...84 Guidance for Documenting Airbag Systems in Future Investigations...86 Conclusions...87 Findings...87 Recommendations...88 Appendix A: National Transportation Safety Board Safety Recommendation Status Key and Safety Recommendations Concerning General Aviation Occupant Protection...90 Appendix B. Shoulder Harness Analysis...98 Injury Reduction from Shoulder Harness Use in General Aviation Airplane Accidents...98 Background...98 Analysis Purpose...99 Method...99 Results Discussion Limitations Appendix C. Federal Aviation Administration Special Conditions for the Certification of Aircraft with Inflatable Restraints Appendix D. Summary of Dynamic Seat/Restraint Tests Required for Title 14 Code of Federal Regulations Part 23 Aircraft Appendix E. Airbag Data Collection Form Appendix F. Injury Details ii

7 Figures Figure 1. A chart showing fatal and nonfatal GA accidents per 100,000 flight hours for the years 1975 through (Accident data source: NTSB; flight hour data source: FAA.)... 2 Figure 2. A chart showing the proportion of injury levels, by occupant, for all GA accidents between 1983 and (Accident data source: NTSB.)... 2 Figure 3. A chart showing the number of airplanes with airbags installed as original equipment grouped by manufacturer (as of August 2010) Figure 4. A pair of drawings showing airbag systems integrated into a 3-point restraint system (left) and a 4-point restraint system (right). The blue arrows indicate the location of the airbag embedded in the restraint Figure 5. A series of images taken from a high-speed video showing the deployment sequence of the AmSafe airbag system in a laboratory sled test. (T refers to time, and ms refers to milliseconds of elapsed time.) Figure 6. A pair of drawings showing basic airbag shapes for the (a) Cirrus and (b) Cessna systems described in this report Figure 7. A chart showing the selection criteria for accidents and incidents that were included in the study Figure 8. A photograph showing seatbelt webbing, load bar, and load mark Figure 9. A pair of photographs showing vent holes from a Cirrus airbag. Photograph a. shows minor fraying, and photograph b. shows squaring. Squaring of the vent hole was used as one indicator that the airbag had sustained loads during the accident Figure 10. A drawing showing the various directions of crash forces as applied to aircraft occupants Figure 11. A chart showing the manufacturers of all airbag-equipped airplanes involved in accidents or incidents during the data collection period Figure 12. A chart showing injury levels among the 161 occupants involved in 88 accidents in airbag-equipped airplanes Figure 13. A chart summarizing the classification of all airbag-equipped airplane events tracked during the study period Figure 14. A photograph of the Cessna 172 Skyhawk instrument panel. The Skylane panel has a similar glass cockpit panel with dual control yokes iii

8 Figure 15. A photograph of an exemplar Cessna airplane seat with a lap belt-mounted airbag system Figure 16. A photograph of the Cirrus SR22 instrument panel Figure 17. A photograph of exemplar Cirrus airplane seats with airbags mounted in the outboard shoulder harnesses Figure 18. A photograph of the exemplar Aviat Husky A-1B instrument panel. (Radio Package 2 panel shown.) Figure 19. A photograph of exemplar Aviat Husky airplane seats with airbags mounted in the right shoulder harness Figure 20. A seating chart from Cirrus SR22, N6568CD, which crashed in Boyceville, Wisconsin. (NTSB accident identification number is CHI06FA218.) Figure 21. A photograph showing the final resting position of Cirrus SR22, N658CD, which crashed in Boyceville, Wisconsin. The photograph was taken facing the nose of the airplane. The two front row seats are denoted with yellow arrows Figure 22. A seating chart from Aviat Husky A-1B, N94HY, which crashed in Owyhee, Oregon. (NTSB accident identification number is SEA06FA168.) Figure 23. A photograph of the wreckage of Aviat Husky A-1B, N94HY, which crashed in Owyhee, Oregon. (The wings were removed postcrash during the recovery of the airplane.) Figure 24. A photograph of Cirrus SR22, N91MB, as it was lifted from the water retention pond where it crashed in Indianapolis, Indiana. (NTSB accident identification number is CHI06FA245.) Figure 25. A seating chart from Cirrus SR22, N91MB, which crashed in Indianapolis, Indiana Figure 26. A photograph showing the seat pan and aluminum EAMs from the two front seats. The left front seat pan and EAM block are on the left side of the photograph. The front of both seat pans is toward the top of the photograph Figure 27. A seating chart from Cessna T182T, N14685, which crashed in Athens, Texas. (NTSB accident identification number is DFW07LA078.) Figure 28. A photograph of the wreckage of Cessna T182T, N14685, which crashed in Athens, Texas Figure 29. A pair of drawings showing pilot and front passenger seats and restraint configurations of a Cessna 172S. The correct latch configuration is shown on the left, and the incorrect configuration is shown on the right iv

9 Figure 30. A photograph of the label placed on the occupant-facing side of the lap belt portion of Cessna airbag-equipped restraints Figure 31. A drawing showing the front seats and seatbelts/shoulder harnesses of the Cessna 172S Figure 32. A seating chart from Cessna T172S, N2190W, which crashed in Fullerton, California. (NTSB accident identification number is LAX08FA301.) Figure 33. A photograph showing the final resting position of Cessna 172S, N2190W, which crashed in Fullerton, California Figure 34. A seating chart from Cessna 172S, N2337F, which crashed in Groton, Connecticut. (NTSB accident identification number is ERA09LA064.) Figure 35. A photograph showing the final resting position of Cessna 172S, N2337F, which crashed in Groton, Connecticut Figure 36. A seating chart from Cirrus SR20, N389CP, which crashed in Green Cove Springs, Florida. (NTSB accident identification number is ERA09LA062.) Figure 37. A photograph showing the final resting position of Cirrus SR20, N389CP, which crashed in Green Cove Springs, Florida Figure 38. A seating chart from Cirrus SR22, N486CD, which crashed in Steamboat Springs, Colorado. (NTSB accident identification number is CEN09LA165.) Figure 39. A photograph showing the final resting position of Cirrus SR22, N486CD, which crashed in Steamboat Springs, Colorado Figure 40. A drawing showing a pair of unbuckled Cirrus SR22 4-point restraint systems Figure 41. A seating chart from Cessna 182T, N1491D, which crashed in Stigler, Oklahoma. (NTSB accident identification number is CEN09LA247.) Figure 42. A photograph showing the final resting position of Cessna 182T, N1491D, which crashed in Stigler, Oklahoma. Two major impacts of the nose into the ground are visible in the foreground Figure 43. A pair of photographs showing seat belt buckles and a buckle label. Photograph a, on the left, shows the primary (top) and child seat (bottom) buckles for the rear seat occupants. Photograph b, on the right, shows the label stitched to the child seat buckles Figure 44. A seating chart from Cessna 172S, N2446F, which crashed in Boyd, Texas. (NTSB accident identification number is CEN09LA442.) Figure 45. A photograph of the final resting position of Cessna 172SP, N2246F, which crashed in Boyd, Texas v

10 Figure B-1. A chart showing the risk ratios and 95-percent confidence intervals for pilot fatal or serious injury (FSI) when using a lap belt only (LB) relative to a lap belt/shoulder harness combination (SH) across multiple conditions vi

11 Acronyms and Abbreviations AmSafe ATD Aviat Avidyne BMI CAB CAMI CAPS Cessna CFI CFR CI CIREN Cirrus EAM EMA FAA FSI GA GAMA GPS HIC LB AmSafe Inc. anthropomorphic test dummy Aviat Aircraft Inc. Avidyne Corporation body mass index Civil Aeronautics Board Civil Aerospace Medical Institute Cirrus Airframe Parachute System Cessna Aircraft Company certified flight instructor Code of Federal Regulations confidence interval Crash Injury Research and Engineering Network Cirrus Aircraft energy absorption module electronics module assembly Federal Aviation Administration fatal or serious injury general aviation General Aviation Manufacturers Association global positioning system head injury criterion lap belt vii

12 LOC MFD ms msl NASA NHTSA NTSB PFD RPM RR SDT SH T TAS TRC USPA VIN loss of control multifunction flight display millisecond mean sea level National Aeronautics and Space Administration National Highway Traffic Safety Administration National Transportation Safety Board primary flight display revolutions per minute risk ratio System Diagnostic Tool lap belt/shoulder harness combination time traffic advisory system transmitter receiver computer United States Parachute Association vehicle identification number viii

13 Executive Summary In 2003, airbags were first certificated for pilot and copilot seats on general aviation (GA) aircraft, and as of August 2010, they have been installed in nearly 18,000 seats in over 7,000 GA aircraft. Unlike automotive airbags that typically deploy from the steering wheel, instrument panel, or above the window, airbags in GA aircraft are installed in the lap belt or shoulder harness portions of the restraint system and are designed to deploy outward from the pilot or occupant. Sled tests conducted under controlled conditions have suggested that aviation airbags may increase survivability and reduce injury in actual aviation accidents; however, no systematic evaluations have been conducted to evaluate their efficacy in real world scenarios. Therefore, in 2006, the National Transportation Safety Board (NTSB) initiated an exploratory case series study to assess airbag performance in GA accidents. The goals of the study were (1) to examine the effectiveness of airbags in mitigating occupant injury in GA accidents, (2) to identify any unintended consequences of airbag deployments, and (3) to develop procedures to assist investigators in documenting airbag systems in future investigations. During the 3-year data collection period, researchers tracked 145 notifications of events (including 88 accidents) involving airbag-equipped airplanes and conducted field investigations of 18 of those events. Ten airbag-equipped GA airplane accidents involving 25 occupants met the study criteria and were subjected to a full review and analysis by a multidisciplinary team. The accidents represented a range of crash severities and included survivable accidents with and without airbag deployments. There were no unexpected deployments or unintended consequences identified during the study period. Overall, when adjusted correctly, the deployment of the airbag systems did not result in any negative outcomes, and in certain cases, deployment may have mitigated the severity of occupant injuries. Of the 88 accidents involving airbag-equipped airplanes that were identified during the study period, about two-thirds (66 percent) had no airbag deployment and no occupant injuries. An additional 22 percent had reductions in survivable space or crash forces that were not survivable. Therefore, airbags would only have been expected to yield a benefit in a relatively small (12 percent) proportion of accidents. Within that window of accident severity, the NTSB concludes that aviation airbags can mitigate occupant injuries in severe but survivable crashes in which the principal direction of force is longitudinal. During the course of the study, the study team also discovered several potential issues that may compromise occupant safety associated with the use, adjustment, or design of restraint systems. The report discusses steps that could be taken to address these safety issues and suggests future research directions in the area of GA occupant protection. Finally, as a result of the study, guidance for NTSB investigators was developed and disseminated, including a formal process for gathering data about airbag installations and deployments in accident aircraft. ix

14 Chapter 1: Introduction General aviation 1 (GA) continues to have the highest accident rates within civil aviation. In 2009, GA accident 2 rates per 100,000 flight hours were 4.7 times higher than those for small commuter and air taxi (14 CFR Part 135) operations and over 40 times higher than those for large transport category (14 CFR Part 121) operations. 3 Of the 1,478 GA accidents that occurred in 2009, 465 (31.5 percent) were classified as serious or fatal, resulting in 475 fatally injured and 278 seriously injured occupants. There are two fundamental ways to reduce the number of injuries and fatalities in GA accidents. The first way is to reduce the number of accidents by making improvements to the aircraft, the flying environment, or pilot performance. The second way is to improve the likelihood that airplane occupants will survive or avoid injury when a crash does occur. As 4 shown in figure 1, rates of both fatal and nonfatal GA accidents per 100,000 flight hours have declined over the past 35 years. Between 1975 and 2009, the fatal accident rate declined by 39.3 percent and the nonfatal accident rate declined by 48.1 percent. In 2009, there were 1.3 fatal and 5.9 nonfatal accidents per 100,000 flight hours. Although accident rates have decreased, the proportion of occupants killed or seriously injured in those GA accidents that occur, shown in figure 2, has changed very little since the early 1980s. In 2009, 18.6 percent of all occupants in GA accidents died, 11.0 percent were seriously injured, percent had minor injuries, and 56.9 percent were uninjured. 1 General aviation is defined as any civil aircraft operation that is not covered under Title 14 Code of Federal Regulations (CFR) Parts 121, 129, and 135, commonly referred to as commercial air carrier operations. 2 An accident is defined as an occurrence associated with the operation of an aircraft which takes place between the time any person boards the aircraft with the intention of flight and all such persons have disembarked, and in which any person suffers death, or serious injury, or in which the aircraft receives substantial damage. The definition of aircraft accident includes unmanned aircraft accident. See 49 CFR Information obtained from the NTSB website < (accessed October 15, 2010). 4 An accident is considered fatal if it involves a fatal injury, which is defined in 49 CFR as any injury that results in death within 30 days of the accident. 5 Serious injury is defined in 49 CFR as any injury that (1) requires hospitalization for more than 48 hours, commencing within 7 days from the date the injury was received; (2) results in a fracture of any bone (except simple fractures of fingers, toes, or nose); (3) causes severe hemorrhages, nerve, muscle, or tendon damage; (4) involves any internal organ; or (5) involves second- or third-degree burns, or any burns affecting more than 5 percent of the body surface. 1

15 Figure 1. A chart showing fatal and nonfatal GA accidents per 100,000 flight hours for the years 1975 through (Accident data source: NTSB; flight hour data source: FAA.) Figure 2. A chart showing the proportion of injury levels, by occupant, for all GA accidents between 1983 and (Accident data source: NTSB.) 2

16 History of GA Occupant Protection Systems The first efforts to improve occupant survival in airplane crashes began not long after the advent of aviation. In his book chapter on the history of crash injury prevention in civil aviation, Richard Chandler, former head of the Federal Aviation Administration s (FAA) Civil Aerospace Medical Institute (CAMI) Protection and Survival Laboratory, states that as early as World War I, lap belt/shoulder harness combinations were used by military aviators. 6 However, according to Chandler, they were primarily designed to keep aviators in place during maneuvers and offered little safety benefit during a crash. By 1928, seatbelts were required in all aircraft, and in 1933, the civil aviation regulations were modified to require seatbelts to be capable of withstanding a load of 1,000 pounds applied in the same manner as a passenger s weight would be applied in a crash. 7 Military research conducted in the 1930s suggested that occupants could survive much greater crash forces when using a lap belt/shoulder harness combination; 8 however, shoulder harnesses were not seriously considered in aircraft design until many years later, partly because of public perceptions that seatbelts were hazardous, and partly because of early designs that were uncomfortable for occupants. 9 In the 1940s and 1950s, the U.S. Department of Agriculture funded a project to develop an airplane for agricultural uses. The design included several crashworthiness features, including a tubular structure that would bend and fall outwardly away from occupants, space between the instrument panel and firewall to permit forward displacement of the panel, removal of sharp or rigid edges from the instrument panel, and lap and shoulder restraints and seat anchorages sufficient to resist failure up to the point of cabin collapse. 10 In 1969, the FAA required that newly type-certificated GA aircraft must have seatbelts and shoulder harnesses for each occupant. 11 However, this requirement did not have a wide impact because it only applied to new type certificates. Manufacturers could continue producing aircraft without shoulder harnesses under existing type certificates. In 1977, the FAA published two regulatory amendments that affected GA aircraft and operations. 12 Title 14 CFR Part 23, which governs the airworthiness standards for GA aircraft, was modified to require shoulder harness installations in all newly manufactured GA aircraft starting in 1978, but only for front seats. Title 14 CFR Part 91, which covers general operating and flight rules, was modified to state that 6 R. Chandler, Accidental Injury: Biomechanics and Prevention (New York: Springer-Verlag, 1993), pp U.S. Department of Commerce, Aeronautics Branch, Aeronautics Bulletin No. 7-F, effective March 1, H.G. Armstrong, Principles and Practice of Aviation Medicine, (Baltimore: Williams and Wilkins, 1939). 9 Chandler, pp F.E. Weick and J.R. Hansen, From the Ground Up: The Autobiography of an Aeronautical Engineer (Washington and London: Smithsonian Institution Press, 1988). 11 Alternately, manufacturers could meet the regulatory requirement by installing lap belts and eliminating injurious objects within the striking radius of the head or by installing lap belts and an energy-absorbing rest to support the arms, shoulders, head, and spine. 12 See Amendment to 14 CFR Part 23 and Amendment to 14 CFR Part 91. Federal Register, vol. 42, no. 116 (June 16, 1977), p

17 required flight crewmembers must use available shoulder harnesses during takeoff and landing. In the 1980s, the National Transportation Safety Board (NTSB) and the FAA engaged in several efforts to improve GA safety. The FAA requested the formation of an independent General Aviation Safety Panel to suggest regulatory and non-regulatory ways for the FAA to promote GA safety. Similarly, the NTSB initiated a GA crashworthiness program with the goal of persuading the FAA to improve regulations regarding the crashworthiness of GA aircraft. 13 In 1985, the NTSB conducted a study of 535 accidents in which at least one occupant was fatally or seriously injured. 14 The NTSB found that shoulder harnesses were available for only 40 percent of occupants in those accidents and that only 40 percent of occupants used the shoulder harnesses that were available, resulting in a total usage rate of 16 percent. The report estimated that if all occupants in the study had worn shoulder harnesses, fatalities in all crashes would have decreased by 20 percent and that 88 percent of seriously injured persons in survivable crashes would have experienced significantly fewer life-threatening injuries. The final phase of the NTSB s crashworthiness study, published in 1985, examined survivable accidents in which occupants died or were seriously injured to identify improvements 15 needed for GA aircraft crashworthiness. The NTSB defined a survivable accident as one in which the forces transmitted to the occupant through the seat and restraint system do not exceed the limits of human tolerance to abrupt accelerations and in which the structure in the occupant s immediate environment remains substantially intact to the extent that a livable volume is provided throughout the 16 crash sequence. The study found that more than half of the seats in the accidents investigated became detached. The report called existing seat design requirements inadequate and supported the use of dynamic seat tests, energy absorbing seats, rip-stop seat pans, and shoulder harnesses to reduce occupant injuries. In 1985, the FAA modified the regulations to require shoulder harnesses in all seating positions of GA airplanes manufactured after December 12, 1986, and amended 14 CFR Part 91 to require all occupants to wear them during takeoff and landing. In 1988, the FAA issued a final rule outlining performance-based dynamic crash test standards for all aircraft carrying no more than nine passengers. Those tests standards remain today and are described in more detail in the 13 The Status of General Aviation Aircraft Crashworthiness, Safety Report NTSB/SR-80/02 (Washington, DC: National Transportation Safety Board, 1980). 14 General Aviation Crashworthiness Project: Phase Two Impact Severity and Potential Injury Prevention in General Aviation Accidents, Safety Report NTSB/SR-85/01 (Washington, DC: National Transportation Safety Board, 1985). 15 General Aviation Crashworthiness Project: Phase 3 Acceleration Loads and Velocity Changes of Survivable General Aviation Accidents, Safety Report NTSB/SR-85/02 (Washington, DC: National Transportation Safety Board, 1985). 16 General Aviation Crashworthiness Project: Phase 1, Safety Report NTSB/SR-83/01 (Washington, DC: National Transportation Safety Board, 1983). 4

18 section later in this chapter, titled Standards and Certification of GA Restraint and Airbag Systems. NTSB Recommendation History In 1964, the Civil Aeronautics Board (CAB) Bureau of Safety (predecessor of the NTSB) recommended that the Federal Aviation Agency (predecessor of the FAA) require shoulder harnesses for each occupant on newly certified GA aircraft; shoulder harnesses and crash helmets for those aircraft involved in hazardous flight, such as aerial applications or aerial surveys; and education for all pilots stressing the desirability of using safety equipment. 17 Since its inception as an independent agency, the NTSB has continued to push for changes to improve occupant survival in aviation and has issued more than 40 recommendations concerning occupant protection in GA aircraft. 18 The majority of those recommendations were issued to the FAA in the 1970s and 1980s and called for the installation, testing, and use of shoulder harnesses in GA aircraft. For example, in response to the FAA s 1977 rulemaking 19 to require shoulder harnesses for pilot and copilot seats beginning in 1978, the NTSB issued Safety Recommendations A and -71, which respectively recommended that the FAA strengthen the rules to require installation of shoulder harnesses at all seat locations and require their installation on all GA aircraft, including those manufactured earlier than In 1985, the FAA modified 14 CFR to require shoulder harnesses in all seats of GA airplanes manufactured after December 12, 1986, and amended 14 CFR Part 91 to require all occupants to wear shoulder harnesses, when available, during takeoff and landing. However, the FAA never modified its regulations to require retrofitting of aircraft manufactured before the 1978 and 1986 regulatory changes. 20 The NTSB also made several recommendations concerning shoulder harnesses and improved survivability in GA aircraft as a result of its GA crashworthiness program in the 1980s. As a result of its 1985 safety report, 21 the NTSB issued four recommendations to the FAA calling for increased performance standards for occupant protection systems and dynamic testing of seat restraint systems, a requirement that all occupants use shoulder harnesses during takeoffs and landings, an advisory circular on GA aircraft occupant protection, and airworthiness directives to address component failures identified in the study. 22 An additional recommendation was issued to the General Aviation Manufacturers Association (GAMA) to encourage its members to identify weaknesses in seat restraint systems that could be easily corrected NTSB/SR-80/ See appendix A for a list of NTSB safety recommendations concerning occupant protection in GA. 19 Federal Register, vol. 50, no. 219 (November 13, 1985), p Safety Recommendation A-77-70, which called for shoulder harnesses at all seat locations, was classified Closed Acceptable Action on March 25, Safety Recommendation A-77-71, which called for the installation of shoulder harnesses on aircraft manufactured before 1978, was classified Closed Unacceptable Action on July 1, NTSB/SR-85/ See Safety Recommendations A through A See Safety Recommendation A

19 Nearly all of the NTSB recommendations concerning GA occupant protection were closed in an acceptable status as a result of the aforementioned revisions to 14 CFR Parts 23 and 91 that took place in the late 1980s, with the exception of Safety Recommendation A-77-71, which called for the retrofit installation of shoulder harnesses in aircraft manufactured before Open NTSB recommendations concerning GA occupant protection include recommendations to the FAA and to the United States Parachute Association (USPA) that call for research and actions to improve restraint systems for parachutists. 24 Additionally, in August 2010, NTSB made two recommendations to the FAA calling for regulatory amendments (1) to require separate seats for every aircraft occupant and (2) to require that each person who is less than 2 years of age be restrained in a separate seat position by an appropriate child restraint system during takeoff, landing, and turbulence. 25 Research on the Effectiveness of Aviation Airbags and Other Occupant Protection Systems According to one study, the most common cause of death noted on autopsies for pilots in GA airplane accidents is blunt trauma, accounting for 86.0 percent of all GA pilot fatalities. 26 The next highest were thermal burns (3.9 percent), drowning (3.6 percent), inhalation of smoke and toxic gases (2.0 percent), and bleeding to death (2.0 percent). Another study analyzed injuries recorded on death certificates for aviation accident related fatalities and determined that 42 percent of fatalities were noted to result from multiple injuries, 22 percent resulted primarily from head injuries, and 12 percent resulted primarily from internal injuries. 27 The researchers suggested that about 20 percent of aviation deaths would be preventable if occupants were protected by better restraint systems. Early airbag-related research sponsored by the FAA Civil Aeromedical Institute compared an inverted-y yoke harness to an instrument-panel-mounted airbag using sled tests with animal (baboon) subjects. 29 With respect to the airbag condition, the authors remarked that all subjects moved within 10 seconds of impact and were alert and active within 20 seconds. In comparison, no other system tested to date resulted in such immediate subject recovery post impact. This may have important implications As of December 6, 2010, Safety Recommendations A through A are all classified as Open Acceptable Response. 25 As of December 6, 2010, Safety Recommendations A and A are both classified as Open Initial Response Received. 26 D.A. Weigmann and N. Taneja, Analysis of Injuries Among Pilots Involved in Fatal General Aviation Airplane Accidents, Accident Analysis and Prevention, vol. 35, no. 4 (2003), pp G. Li and S. Baker, Injury Patterns in Aviation-Related Fatalities: Implications for Preventative Strategies, American Journal of Forensic Medicine and Pathology, vol. 18, no. 3 (1997), pp Later renamed the Civil Aerospace Medical Institute. 29 Subjects had lap belts in both conditions. See R.G. Snyder, J.W. Young, and C.C. Snow, Experimental Impact Protection With Advanced Restraint Systems: Preliminary Primate Tests With Air Bag and Inertia Reel/Inverted-Y Yoke Torso Harness, AM-69-4 (U.S. Department of Transportation, Federal Aviation Administration, Office of Aviation Medicine, 1969), p

20 where immediate evacuation is important, provided that the deflated bag does not become an obstacle. An FAA review described other early conceptual research, comparing various airbag system configurations including floor-mounted, instrument panel-mounted, seat-mounted, and restraint-mounted designs, all of which included two airbags for both longitudinal and vertical impacts. 30 The review suggested that restraint-mounted airbags were superior to other configurations, especially with respect to retrofitting aircraft. Subsequent research using an anthropomorphic test dummy (ATD) in catapult-and-track crash simulations compared levels of crash protection offered by lap belts alone compared to 31 lap belt/shoulder harness combinations and lap belt/airbag combinations. Both the lap belt/shoulder harness combination and the lap belt/airbag combination conditions were superior to lap belt alone in reducing head and chest accelerations. At the time, the potential risks associated with inadvertent airbag deployment and the challenges in developing a reliable crash sensor made the lap belt/shoulder harness combination the most practical approach. However, the report also recommended that developments in inflatable restraint systems be closely monitored for new technology which would further improve occupant protection. When such technology is established, further evaluation testing should be conducted. 32 Other laboratory sled tests using ATDs compared lap belts with and without aviation airbags and found that airbag systems were associated with a reduction in head and pelvis accelerations and in head injury criterion (HIC) 33 in head-on crashes. 34 Military research using actual pilots in helicopter simulators has shown that pilots were able to regain aircraft control after an average of 4 seconds following an inadvertent airbag deployment. 35 Similar research conducted to evaluate emergency egress from a water impact scenario employed a mock-up helicopter cockpit in a dunker simulator with actual helicopter pilots. 36 The study showed that deployed airbags did not significantly hinder pilots egress from the cockpit. 30 R.W. Carr and N.S. Phillips, Inflatable Restraint Concept for General Aviation Aircraft, FAA-RD-73-3 (Washington, DC: Beta Industries, Inc. Prepared for U.S. Department of Transportation, Federal Aviation Administration, 1973). 31 J.A. Sommers, Comparison of General Aviation Occupant Restraint Systems, FAA-RD (Washington, DC: National Aviation Facilities Experimental Center Prepared for U.S. Department of Transportation, Federal Aviation Administration, 1973). 32 Sommers, p The HIC was proposed by the National Highway Traffic Safety Administration (NHTSA) in 1972 and is a measure of the likelihood of head injury, with higher values indicating an increased likelihood. 34 L.W. Roemke, The Inflatabelt Occupant Restraint System, pp in Proceedings of the Technical Cooperative Program Workshop: Inflatable Restraints in Aviation, TTCP/HUM/00/009 (Huntsville, Alabama: Technical Cooperation Program, 2000). 35 F. Brozoski and others, Effect of Airbag Deployment on Helicopter Flight Control, pp in Proceedings of the Technical Cooperative Program Workshop: Inflatable Restraints in Aviation, TTCP/HUM/00/009 (Huntsville, Alabama: Technical Cooperation Program, 2000). 36 M.R. Schultz, A.C. Schoenbeck, and G. Wittlin, Airbag Performance and Design Issues for Naval Aircraft Applications, pp in Proceedings of the Technical Cooperative Program Workshop: Inflatable Restraints in Aviation, TTCP/HUM/00/009 (Huntsville, Alabama: Technical Cooperation Program, 2000). 7

21 Research Methods and NTSB Research Research methods that are used to evaluate a safety technology vary depending on its stage of implementation. During the developmental stages of a new safety technology, a considerable amount of research is performed using simulators and laboratory testing. The benefits of this type of research are many. It allows for strict control of test variables, rapid results, and is far less likely to put human subjects at risk of injury. However, the main drawback is that such research cannot replicate the complexity of the applied environment. During the early implementation stage of a new safety technology, the research methods shift toward observational, descriptive case studies. This approach, employed in the present study, is useful for developing an initial understanding of how users interact with the system, for identifying any unintended problems, for generating hypotheses that can be tested in future studies, and for establishing the data elements that could be used to test those hypotheses. The case study approach has been successfully applied by the NTSB in evaluating lap belts, 37 lap/shoulder belts, 38 and airbags 39 in highway passenger vehicles and shoulder harnesses and energy-absorbing seats in GA. 40 Once a technology has been implemented on a wider scale, empirical research can be used to quantify the effectiveness of a countermeasure. The NTSB conducted such an empirical analysis on the efficacy of lap belt/shoulder harness combinations in GA during the course of this study. Using its extensive database of aviation accidents, the NTSB analyzed over 37,000 single engine airplane accidents between 1983 and 2008, and found that the risk of death or serious injury for pilots who used lap belts only was nearly 50 percent higher when compared to pilots who wore lap belt/shoulder harness combinations. Previously, these analyses had only been performed on specialty groups, 41 with findings that were limited by small sample sizes and an exclusive focus on fatalities as an outcome measure. This NTSB analysis, described in detail in Appendix B, definitively shows the benefit of shoulder harnesses in reducing injuries and fatalities in GA accidents. 37 Performance of Lap Belts in 26 Frontal Crashes, Safety Study NTSB/SS-86/03 (Washington, DC: National Transportation Safety Board, 1986). 38 Performance of Lap/Shoulder Belts in 167 Motor Vehicle Crashes (Volume 1), Safety Study NTSB/SS-88/02 (Washington, DC: National Transportation Safety Board, 1988). 39 The Performance and Use of Child Restraint Systems, Seatbelts, and Air Bags for Children in Passenger Vehicles Volume 1: Analysis, Safety Study NTSB/SS-96/01 (Washington, DC: National Transportation Safety Board, 1996). 40 NTSB/SR-85/ D.M. Bensyl, K. Moran, and G.A. Conway, Factors Associated With Pilot Fatality in Work-Related Aircraft Crashes: Alaska, , American Journal of Epidemiology, vol. 154, no. 11 (2001), pp ; L.G. Gillis, G. Li, and S.P. Baker, General Aviation Crashes Involving Military Personnel as Pilots, Aviation Space and Environmental Medicine, vol. 72, no. 11 (2001), pp ; S.P. Baker and M.W. Lamb, Hazards of Mountain Flying: Crashes in the Colorado Rockies, Aviation Space and Environmental Medicine, vol. 60, no. 6 (1989), pp ; G. Li and S.P. Baker, Correlates of Pilot Fatality in General Aviation Crashes, Aviation Space and Environmental Medicine, vol. 70, no. 4 (1999), pp ; P.S. Rostykus, P. Cummings, and B.A. Mueller, Risk Factors for Pilot Fatalities in General Aviation Airplane Crash Landings, JAMA, vol. 280, no. 11 (1998) pp

22 Automotive Airbag Systems Airbags have been used in the automotive fleet for more than three decades, and the history of their adoption and associated research to evaluate them can inform the study of aviation airbags. Initially introduced as standard equipment as early as the mid-1970s, automotive airbags were mandated by Congress for front seats in all passenger vehicles by The efficacy of automotive airbags has been evaluated in numerous large-scale empirical research studies. Early studies showed that fatalities were about 11 percent lower in airbag-equipped vehicles for both drivers 42 and right front passengers. 43 Beginning in 1993, the NHTSA Special Crash Investigations program 44 and the NTSB 45 conducted investigations and documented cases in which certain occupants, particularly children and infants, seated in the right front passenger seat had been killed by airbags in survivable low-speed crashes. Concern about airbag-induced fatalities led to a large-scale education campaign to educate caregivers about proper child seatbelt and safety seat use; it also prompted amendments to vehicle design regulations and the development of a new generation of depowered airbags to reduce the aggressivity of the bag. 46 More recent studies have demonstrated that the use of the depowered airbags has led to a significant reduction in risk of dying in frontal collisions among right front seat passengers under age 10, with no reduction in protection for other occupants. 47 In the case of automotive airbags, there has been a continuous cycle of testing, design, iteration, and field research with the goal of improving survivability among all occupants. The cycle has continued with the development and introduction of new technologies, such as rear seat airbags that deploy between rear seated passengers 48 and inflatable rear seatbelts designed to increase the surface area of the seatbelt and disperse crash loads across the body C.J. Kahane, Fatality Reduction by Air Bags: Analyses of Accident Data Through Early 1996, DOT HS (Washington, DC: U.S. Department of Transportation, National Highway Traffic Safety Administration, 1996). 43 E.R. Braver and others, Reductions in Deaths in Frontal Crashes Among Right Front Passengers in Vehicles Equipped with Passenger Air Bags, Journal of the American Medical Association, vol. 278, no. 17 (1997), pp Special Crash Investigations: First Generation Frontal Air Bags A Model for Future Corrective Action, DOT HS (U.S. Department of Transportation, National Highway Traffic Safety Administration, 2010). 45 See NTSB/SS-96/ S.A. Ferguson and L.W. Schneider, An Overview of Frontal Air Bag Performance With Changes in Frontal Crash-Test Requirements: Findings of the Blue Ribbon Panel for the Evaluation of Advanced Technology Air Bags, Traffic Injury Prevention, vol. 9, no. 5 (2008), pp E.R. Braver and others, Deaths Among Drivers and Right-Front Passengers in Frontal Collisions: Redesigned Air Bags Relative to First-Generation Air Bags, Traffic Injury Prevention, vol. 9, no. 1 (2008), pp Information obtained from AutoWeek website < > (accessed May 20, 2010). 49 Information obtained from Wired website < (accessed May 20, 2010). 9

23 Description of Current GA Airbag Systems Although airbag systems are now standard in the automotive industry, their use in aviation is relatively new. In addition, unlike most automotive applications, aviation airbags are incorporated into the lap belt or shoulder harness portions of the restraint system rather than mounted in the vehicle. Airbags were introduced into commercial aircraft at bulkhead positions in 2001 as a means of complying with certification standards promulgated in 1988 relating to emergency landing dynamic conditions described in 14 CFR In 2003, airbags were first certificated for use on GA aircraft, and in 2005, GA airplane manufacturers began offering airbags as standard equipment on pilot and copilot seats. Figure 3 depicts the number of installations grouped by manufacturer. As of August 2010, airbags have been installed in nearly 18,000 seats in over 7,000 GA aircraft. Airbags are now included as standard equipment in the pilot and copilot seats of over half of all newly manufactured single-engine GA airplanes; however, because airplanes remain in service for many years, airbag-equipped airplanes currently account for less than 5 percent of the active GA fleet. 50 Appendix C contains a list of airplane models that have been approved to have airbags installed as standard equipment. Figure 3. A chart showing the number of airplanes with airbags installed as original equipment grouped by manufacturer (as of August 2010). 50 According to the FAA s General Aviation and Part 135 Activity Survey for calendar year 2008, there were 177,096 active GA airplanes that year. 10

24 Currently, AmSafe Inc. (AmSafe) is the only company certified to manufacture aviation airbag systems for commercial and private aircraft. The AmSafe Aviation Inflatable Restraint System, Version 23, is described by the manufacturer as a self-contained, modular airbag restraint system specifically designed to improve occupant protection from serious head-impact injury during an otherwise survivable aircraft accident, thus enhancing the occupant s ability to exit the aircraft. 51 As previously discussed, the airbag is installed in the lap belt or shoulder harness portions of the restraint system and deploys outward from the pilot or occupant. For 2- and 3-point restraint systems, 52 the airbag is embedded in the lap portion of the restraint; for 4- and 5-point restraint systems, the airbag is typically embedded in the outboard shoulder harness. Figure 4 displays examples of 3- and 4-point airbag-equipped restraint systems. The airbag restraint systems employ attachment points that are identical to restraint systems without airbags. As such, few design changes have been necessary to equip GA aircraft with airbag systems. Figure 4. A pair of drawings showing airbag systems integrated into a 3-point restraint system (left) and a 4-point restraint system (right). The blue arrows indicate the location of the airbag embedded in the restraint. Airbag Deployment Figure 5 depicts a series of photographs showing a typical airbag deployment during a laboratory sled test with a 3-point restraint system. A device known as the electronics module assembly (EMA) contains the crash sensor that provides the signal to deploy the airbag system. 51 Information obtained from AmSafe website < (accessed January 6, 2010). 52 When referring to a seatbelt as a 2- or 3- point restraint system, this refers to the number of anchor points for the seatbelt. For example, a 2-point restraint system is typically a lap belt, and a 3-point restraint system is typically a lap belt with a single diagonal shoulder harness. Two-point systems are primarily used in air transport category aircraft. 11

25 Unlike automotive airbags, which use electronic sensors, the crash sensor used in GA aircraft is a mechanical, spring-mass-damper type sensor that is mounted to the structure of the aircraft beneath the floor in the vicinity of the seats. The EMA connects to a cable harness that then splits to each seat s airbag system. One EMA is capable of controlling airbags for up to three seats. Figure 5. A series of images taken from a high-speed video showing the deployment sequence of the AmSafe airbag system in a laboratory sled test. 53 (T refers to time, and ms refers to milliseconds of elapsed time.) 53 Photographs provided by AmSafe. 12

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